Epidemiologic Notes and Reports Maternal Deaths Associated
with Barbiturate Anesthetics -- New York City

While reviewing pregnancy-related deaths in New York City since
1980, the New York City Bureau of Maternity Services and Family
Planning noted that seven deaths were associated with the
administration of an ultrashort-acting barbiturate anesthetic
(Brevital) for termination of pregnancy. All seven women suffered
cardiorespiratory arrest either during induction or shortly
thereafter
on the operating room table or in the recovery room.

All seven women were black. Five were 21 years of age or
younger. The mean gestational length was 13 weeks; cases included
both first- and second-trimester termination procedures. Two
procedures were performed in hospitals, four in free-standing
clinics,
and one in a private physician's office. The dose recommended for
methohexital sodium (Brevital) is 1.5 mg/kg body weight, with an
induction dose of 75-100 mg administered intravenously (IV) (1).
The
mean dose for six of the seven women reviewed was 2.4 mg/kg, with a
range of 1.0 mg/kg to 4.5 mg/kg (Table 1).

An expert advisory panel, convened by the New York City
Department
of Health (NYCDH), reviewed charts, termination-of-pregnancy
certificates, and autopsy reports. The panel concluded that these
deaths were related to complications of anesthesia and that black
women under 25 were overrepresented among the decedents, since they
comprised only 26% of all women obtaining abortions in New York
City
during the same period (2). New York City's Commissioner of Health
issued an alert (3) to physicians and administrators stipulating
that
standards set by the Joint Committee on the Accreditation of
Hospitals
(JCAH) (4), the American College of Obstetricians and Gynecologists
(5), and the NYCDH (6) be met whenever general anesthesia is
administered.

Because of concern by the NYCDH, abortion mortality data
collected
by CDC were reviewed to further describe the epidemiology of
abortion
risks in New York City compared with the United States as a whole.
CDC has identified and investigated 193 legal-abortion-related
deaths
that occurred in the period 1972 through March 1985.

The overall abortion-related mortality rate in New York City
between 1972 and 1981 was higher (though not statistically
significantly) than in the other parts of the country for white
women,
for women of black and other races, and for women of all races
combined. Mortality rates for 1982-1985 are not included because
the
total numbers of abortions for those years are not yet known.

Of the 193 legal-abortion-related deaths, 27 (14%) were
attributed
to complications of general anesthesia. The proportion of
legal-abortion-related deaths attributed to complications of
general
anesthesia was significantly higher in New York City than in the
remainder of the United States. This finding persisted throughout
the
period 1972-1985 (Table 2). Comparisons of women dying from
complications of general anesthesia with women dying from other
causes
in New York City and in other places found the following: in New
York
City, both groups had similar distributions by age, race, marital
status, and gravidity; in places other than New York City, a
significantly higher proportion of blacks were among women dying
from
complications of general anesthesia; and in both comparisons, a
significantly higher proportion of women dying from complications
of
general anesthesia died during the first trimester.

Regarding type of anesthetic, CDC data reveal that, among the
27
women whose deaths were attributed to complications of general
anesthesia, the type of anesthetic used was known only in 23 cases.
In 21 cases, short-acting barbiturates were used (Brevital in 16,
Pentothal in three, Surital in one, and unspecified barbiturates in
one). The dose employed was stated in only four cases (in addition
to
the above seven cases reported from New York City), but the women's
weights were not stated.

Thus, a large percentage of deaths due to complications of
general
anesthesia was associated with the use of short-acting
barbiturates.
However, based on available information, a drug-specific mortality
rate could not be estimated, nor could a
general-anesthetic-specific
mortality rate be calculated.
Reported by W Chavkin, MD, L Fernandez, M Harris, MD, GK Higginson,
MD, J Pakter, MD, New York City Dept of Health; Pregnancy
Epidemiology
Br, Div of Reproductive Health, Center for Health Promotion and
Education, CDC.

Editorial Note

Editorial Note: The higher overall legal-abortion-related
mortality
rate in New York City as compared with that in other parts of the
United States between 1972 and 1981 may be due to the fact that
women
obtaining abortions in New York City during that period were in a
higher risk group than women obtaining abortions in other parts of
the
United States. CDC abortion surveillance data show that, compared
with women obtaining abortions in other parts of the United States,
the New York City women were generally older, a higher proportion
were
of black and other races, and a higher proportion obtained their
abortions during the second trimester. The significantly increased
proportion of abortion-related deaths associated with
general-anesthesia complications in New York City may be partially
explained by the more frequent use of general anesthetics for
performance of abortions in New York City than in the other parts
of
the country (7).

Previous studies have shown that, compared with local
anesthetics,
the use of general anesthesia for induced abortion during the first
trimester was associated with a twofold to fourfold increased risk
of
death (8). However, general anesthetics have been frequently used
when abortions are performed. It is estimated that general
anesthetics were used for approximately 46% of all abortions done
in
hospitals during 1971-1975 (9) and approximately 27% of all
abortions
done in clinics during 1976-1977 (10).

The fact that most deaths due to general anesthesia occurred
during the first trimester may be expected, since more than 85% of
all
abortions done in the United States between 1972 and 1981 were done
during the first trimester (11) and since general anesthesia is
more
commonly employed during first-trimester procedures than
second-trimester procedures. Data from the Joint Program for the
Study of Abortion reveal that, between 1975 and 1978, 26% of
first-trimester abortions were done under general anesthesia,
compared
with 13.6% of those done during the second trimester (12).

Short-acting barbiturates have an important place in the
practice
of anesthesiology. They are the IV anesthetics of choice for most
anesthesiologists. They are used to induce general anesthesia and
are
commonly used for maintenance during procedures lasting 15-20
minutes
(11). However, the frequency of using short-acting barbiturates
for
pregnancy termination procedures is not known.

The deaths due to complications of general anesthesia
underscore
the need for close and continuous supervision of general-anesthesia
administration by a qualified anesthesiologist, adequate
recovery-room
monitoring, and particular care in dose calculation using patient
weight. Investigation of seven general anesthetic-related deaths
by
the New York City Bureau of Maternity Services and Family Planning
revealed that four of six women were given overdoses of
methohexital.
Data to compare adverse reactions associated with the use of
methohexital for other procedures are not available. The above
analysis demonstrates an increase in the contribution of
general-anesthesia complications to abortion-related deaths. While
the overall abortion mortality rate based on deaths reported to CDC
declined by 87% from 1972 to 1981 (11), the proportion of
abortion-related deaths due to complications of general anesthesia
increased from 11% between 1972 and 1979 to 29% between 1980 and
1985
(Table 2). Most of those deaths (24 of 27 (89%)) occurred during
the
first trimester. The increased risk of using a general anesthetic
rather than a local anesthetic for first-trimester abortion has
been
documented (8). Clinicians should carefully review their use of
general anesthetics for pregnancy-termination procedures,
especially
during the first trimester.

References

New York City Department of Health. Unpublished data based on
analysis of Termination of Pregnancy Certificates.

New York City Commissioner of Health. Alert to all
obstetricians,
gynecologists, anesthesiologists, directors of free-standing
Ob/Gyn clinics and hospital administrators (Letter). 1985 (May
13).

Joint Commission on the Accreditation of Hospitals. Hospital
accreditation manual. Chicago, Illinois: Joint Commission on
the
Accreditation of Hospitals, 1985.

American College of Obstetricians and Gynecologists. Standards
for obstetric-gynecologic services, 5th ed. Washington, D.C.:
American College of Obstetricians and Gynecologists, 1982.

New York City Department of Health. Guidelines for
out-of-hospital late abortions ("second trimester abortions").
New York City Department of Health, 1985.

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